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Treating the Whole Person—Social Determinants of Health

In the real world, many things other than underlying health conditions contribute to the overall health of an individual or specific population. Complex and overlapping social, economic, environmental, and societal issues such as alcohol and drug use, income and job security, housing conditions, transportation challenges, and much more can interfere with treatment plans or even and exacerbate chronic diseases, and create a significant negative effect on the overall health of an individual and the population. Getting to the root causes of these issues by identifying social determinants of health (SODH) alongside medical and behavioral issues and developing interventions to address them will help us turn the tide so that vulnerable populations whose medical care is negatively affected by SDOH are on a path to deal with all their issues so that they can become healthier.

It’s important to understand that the healthcare system does not operate in isolation. A doctor may provide the highest quality evidence-based medicine available, but after people are treated, they leave the medical facility and go back out into an environment that may prevent them from fulfilling their treatment plan. Likewise, there may be socioeconomic factors that work against the treatment that the provider is unaware of, but had they known they may have provided a different course of treatment or offer additional services. The specific challenges vary, including everything from a lack of access to healthy foods, to the inability to take time off work for appointments, to transportation to appointments and the pharmacy, to pill rationing because a patient can’t pay for a prescription or get to the pharmacy for a refill. But the bottom line is that if we don’t understand and address what our patients are facing in their daily lives, they won’t get the most out of their healthcare.

To solve healthcare, we need to think more broadly, understanding what patients are facing and what their lives are like so we can treat the whole person rather than just their medical symptoms. Enlisting patients as partners in care rather than expecting them to adhere to a prescribed path will provide insight into the people and their circumstances, only some of which are controllable.

GSI Health helps your care team identify and address medical, behavior, and social determinants in a single care plan and collaborate with the community to address those factors that stand in the way of good outcomes. Coordinating care across the continuum will help ensure that at-risk patients receive the right treatment at the right time to improve their health.

“GSI Health’s platform helps us with transitions in care, enabling us to intervene with medication and home care to avoid admissions and readmissions. Other health homes don’t have this capability, and it’s not happening consistently across the state.”

Maimonides Medical Center

Over 600,000 Medicaid lives across the U.S. are being care managed using GSIHealthCoordinator.

“We were able to leverage the technology to help us find our patients, evaluate acuity, prioritize, and coordinate actions, even when all other services were down.”

Kathleen Donaldson, Director of IT Home- and Community-Based Care, Health Home Partners of Western NY

Chilmark: Unlike some vendors, the company does not see ongoing professional services and support as a premium service but, rather, as part of building an “embedded” relationship with its clients that begins with solution implementation within a 60- to 90-day period.

Orchestrates care, including interventions for SDOH, with real-time clinical, social, and behavioral information to a patient-centric care team, ensuring transparency and alignment

Care team collaboration

Build care teams that can include treatment or services to address patient SDOH across multiple inpatient, ambulatory, and community-based settings

Universal care plan

Track and coordinate issues, goals, and interventions that include SDOH in a comprehensive care plan, highlighting each patient’s needs and who in the care team is addressing each intervention in the care plan

Service tracking and reporting for care management, patient outreach, and encounters

Flexible and comprehensive analysis and reporting enabling you to track the performance of your care teams, identify areas for improvement, ensure payments, and enforce consistency and compliance

Care manager

Assign a central point of contact to make the care team more efficient, support transitions in care, fill in the gaps, and effectively manage patients to improve their health

Real-time alerts and messages

Provide instant notification of hospital encounters and communication tools for referral management with SDOH service providers

Patient engagement

Enables teams to more effectively communicate with the patient about their care needs and intervention steps, and promote medication adherence and the use of ambulatory care before patient conditions become critical

Consent management across population and providers

Enables information sharing so you can bring SDOH service providers into your care teams

Healthcare Solved.

Healthcare today is a problem, and while we cannot guarantee a world free of health issues, we can work towards a world where the care everyone receives for those issues is optimized.

We are ushering in a future where data-driven technology optimizes overall care delivery, improving the health of entire populations and solving the problem of uncoordinated, under-informed healthcare that is being practiced in today’s system. Read more about our vision.